Update on COVID-19 Projections

Science Advisory and Modelling Consensus Tables November 26, 2020 Key Findings

• Key indicators of the Pandemic are flattening in some regions but the impact of the Pandemic still varies widely across regions. • Long-Term Care Home resident mortality continues to increase. • ICU occupancy continues to increase and will hit 200 beds in December under any scenario. • It is difficult to determine whether we are seeing a turnaround in case growth. Unlikely to see changes in ICU use until two weeks following decline in cases. • Access to care continues below 2019 levels adding to the access to care deficit. • Some communities face a much higher burden from the Pandemic because of long-standing structural factors that lead to higher exposure to COVID-19. One- size-fits-all public health interventions are unlikely to have the same impact in some communities.

2 Total new cases per 100,000 residents per week across PHUs Recent data may be incomplete

3 Data Source: Case and Contact Management System (CCM), extracted November 24 New cases with no epidemiological Link across PHUs

Recent data may be incomplete

4 Data Source: Case and Contact Management System (CCM), extracted November 24 COVID-19 testing % positivity across PHUs

Data Source: Ontario Laboratory Information System (OLIS), extracted via MOH SAS VA November 24 Percent of tests processed within 2 days across PHUs

6 Data Source: Ontario Laboratory Information System (OLIS), extracted via MOH SAS VA November 24 Weekly % positivity by age group

Weekly % positivity by age group

Month Apr2020 May2020 Jun2020 Jul2020 Aug2020 Sep2020 Oct2020 Nov2020

Week No 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 Age Group 75+ 16.4 11.0 5.0 4.3 3.4 4.7 5.3 3.2 2.9 1.8 1.0 0.9 0.6 0.6 0.4 0.4 0.3 0.2 0.2 0.3 0.4 0.3 0.5 0.5 1.1 1.3 1.4 1.8 2.3 2.8 3.6 3.3 3.1

65to74 11.4 7.2 5.5 4.4 3.6 4.1 3.8 1.9 1.3 0.9 0.5 0.5 0.4 0.4 0.4 0.3 0.4 0.2 0.3 0.3 0.4 0.5 0.5 0.7 1.0 1.2 1.3 1.7 1.9 2.2 2.6 3.4 3.4

55to64 11.4 8.6 6.3 4.8 3.7 4.9 5.7 2.7 2.0 1.0 0.9 0.6 0.6 0.4 0.6 0.5 0.4 0.4 0.3 0.4 0.3 0.5 0.6 0.8 1.2 1.4 1.6 2.3 2.4 2.4 3.0 3.4 3.2

45to54 10.9 8.2 6.2 5.3 4.2 4.6 6.6 3.3 2.2 1.2 1.1 0.7 0.8 0.7 0.7 0.7 0.5 0.5 0.4 0.5 0.5 0.6 0.8 1.0 1.4 1.9 1.9 2.7 2.8 3.0 3.8 4.4 3.9

35to44 8.3 7.1 5.7 4.3 3.3 3.9 5.7 3.4 2.3 1.3 1.4 1.0 0.9 0.8 0.7 0.7 0.5 0.5 0.5 0.4 0.5 0.7 0.8 1.0 1.2 1.5 1.7 2.3 2.7 2.9 3.7 4.5 3.9

25to34 8.7 7.4 6.2 5.2 4.1 4.9 6.2 3.7 2.4 1.4 1.5 1.2 1.0 0.9 1.0 0.9 0.5 0.5 0.6 0.6 0.6 0.9 1.3 1.8 2.1 2.5 2.3 2.9 3.3 3.5 4.2 5.0 4.7

18to24 9.1 7.8 6.5 4.1 4.0 4.4 6.2 3.6 2.5 1.4 1.4 1.1 0.9 0.9 0.9 1.1 0.8 0.7 0.5 0.7 0.9 0.8 1.6 2.4 2.8 3.6 2.6 3.5 4.0 4.4 4.8 5.7 5.3

14to17 5.9 7.1 4.8 3.7 3.4 5.0 6.6 2.2 2.9 1.5 1.6 1.4 1.3 1.1 1.4 1.3 1.4 1.2 1.1 0.8 1.3 1.7 1.8 1.7 1.5 1.9 2.1 2.9 4.0 4.4 5.4 6.6 5.6

9to13 5.7 6.2 4.9 5.8 5.0 5.5 6.5 4.3 3.7 3.4 2.4 1.9 1.0 1.5 1.2 1.7 1.3 0.8 1.4 1.0 1.5 1.4 1.4 0.9 0.8 0.9 1.2 1.8 2.8 3.7 5.0 4.6 5.6

4to8 1.9 4.0 2.3 4.1 2.2 2.9 3.4 3.5 3.4 2.1 2.7 1.7 1.2 0.9 1.1 1.2 1.0 1.0 0.7 0.8 0.5 0.8 0.6 0.5 0.3 0.4 0.9 1.5 2.7 2.7 3.6 4.0 4.5

0to3 1.4 1.5 1.4 1.5 1.5 2.1 2.1 1.3 1.1 1.8 1.3 1.3 0.7 1.4 0.8 1.2 0.4 0.8 0.5 0.3 0.5 0.5 0.3 0.4 0.6 0.7 1.3 2.7 2.2 2.6 3.0 5.2 3.6

Total 11.3 8.5 5.7 4.6 3.7 4.5 5.6 3.1 2.3 1.3 1.1 0.9 0.7 0.7 0.7 0.7 0.5 0.5 0.4 0.5 0.5 0.7 0.9 1.2 1.3 1.6 1.8 2.4 2.8 3.1 3.7 4.3 4.0

Legend:

Data Source: Ontario Laboratory Information System (OLIS), MOH – extracted from SAS VA Nov 24. Note: Includes all data submitted to OLIS up to Nov 23, 2020. The last six days are considered interim data (week 46) and subject to change Weekly % positivity = total number of positive tests within the week (based on reported date)/COVID tests within the week Cases in LTC flattening while cumulative mortality has increased (64 deaths in the past 7 days). LTC Home cases and outbreaks COVID-19 cases and deaths for LTC residents and staff Current status (Nov 24) 800 104 Long term care (LTC) homes currently 700 Daily Deaths, Residents Daily Deaths, Staff in outbreak, 964 active confirmed cases in 600 these homes Daily Active Cases Residents Daily Active Cases Staff 500 542 resident, 453 staff active cases in total Cumulative deaths since Aug 1 400 2,173 cumulative resident deaths, 8 cumulative staff deaths 300

34 of the 104 homes in outbreak are based 200 on 1 staff case 100 There have been 328 resident deaths since 0 Aug 1st, 64 of which have been in the past Aug 1 Aug Sep 1 Sep 15 Oct 1 Oct 15 Nov 1 Nov 7 days 15 15

Data Source: Ministry of Long Term Care Tracker. Data are self-reported by the long-term care homes to the Ministry of Long-Term Care. Daily case and death figures may not immediately match the numbers 8 posted by the local public health units (i.e. iPHIS database) due to lags in reporting time. A number of jurisdictions struggle to control case numbers following public health interventions

Number of Cases per Day (other countries aligned at 10/100,000) 10,000 ON 1.05 9,000 Michigan 8,000 Netherlands

7,000

6,000

5,000 UK ON 1.03

4,000 France NumberCases of 3,000 Germany

2,000 ON 1.01 ON 1.00 1,000

ON 2nd wave - Daily ON 2nd wave - 7-day average ON Constant ON 1.01 Partial or full lockdown (according to the country’s trajectory – does not ON 1.03 ON 1.05 France Germany match date on horizontal axis as epi curves are aligned at 10 cases/100,000/day) Netherlands UK Michigan COVID-19 Hospitalizations continue to rise

550

500 63.2% increase in Confirmed COVID19 Acute Inpatients (excluding ICU) hospitalizations over Confirmed COVID19 ICU Patients 450 most recent 4 weeks

400

350

300

250

200

150

100

0 1-Aug 8-Aug 15-Aug 22-Aug 29-Aug 5-Sep 12-Sep 19-Sep 26-Sep 3-Oct 10-Oct 17-Oct 24-Oct 31-Oct 7-Nov 14-Nov 21-Nov 10 Data Sources: Daily Bed Census Summary COVID-19 Report + Critical Care Information System. Extracted via MOH SAS VA November 24 Projections: ICU Occupancy > 200 beds under all scenarios

400

350

300

250

200

150

100

ON ON 1.0 ON 1.01 ON 1.03 ON 1.05 France Germany Netherlands UK Michigan

11 Access to care continues well below 2019 volumes

80% 12,000 Surgical Resume LTC Directive #2 LTC Action Plan Restart (re)admissions 60% 10,000 40%

20% 8,000

0% 6,000

-20%

Active COVID Cases COVID Active 2020 vs 2019 (%) 2019 vs 2020 Active COVID Cases -40% Diagnostic Imaging 4,000 Surgery -60% ALC (Acute) 0% Line (No Change vs 2019) 2,000 -80% ER ER (Projected from triage volumes in eCTAS) Occupancy Rate -100% 0 The impact of the COVID-19 epidemic in Ontario is not evenly distributed

FSA, Forward Sortation Area 13 Household density and occupation places individuals and relations most at risk of COVID-19

2,000

• ↑ Odds for COVID-19 if Areas with lowest % of 1,800 homes considered residing in neighbourhoods suitable housing with 1,600 1,400

• Higher household density/size 1,200

• Higher proportion of essential 1,000 19 19 100,000 / Cases Population service workers (measured by - 800

proxies for occupation) 600 • Steeper ↑ in COVID-19 cases 400 Cumulative Cumulative COVID Areas with highest % 200 of homes considered in neighbourhoods with suitable housing

lowest % of suitable housing 0

07/19 03/11 03/21 03/31 04/10 04/20 04/30 05/10 05/20 05/30 06/09 06/19 06/29 07/09 07/29 08/08 08/18 08/28 09/07 09/17 09/27 10/07 10/17 10/27 Suitable 03/01 Housing Decile: 1 2 3 4 5 6 7 8 9 10 City of Toronto https://www.medrxiv.org/content/10.1101/2020.11.09.20223792v1 14 One-size-fits-all approaches lead to prevention gaps

Neighbourhood A Neighbourhood B

10% No Interventions 9% Interventions ↓ transmission risk by 8% 25% in both neighbourhoods

7% Interventions ↓ transmission risk by only 10% in neighbourhood A 6% PREVENTION GAP

3% Proportion of PopulationInfected 2%

0% 0 20 40 60 80 100 120 140 160 180 200 220 240 260 280 300 0 20 40 60 80 100 120 140 160 180 200 220 240 260 280 300 prevention gap = conditions that lead to disproportionate risks of acquisition and/or onward transmission → increase R, sustain transmission & “micro-epidemics” 15 Key Findings